Coverage Flashcards
Coverage Requirements
- Claimant must be an employee
- Claimant must sustain either a personal injury or suffer from an occupational disease
- The injury-causing event or occupational disease must both arise out of and be in the course and scope of employment
- The employee must establish a disability AND
- There must be a related wage loss
Employee
An employee is defined as : Persons performing services in a trade, business, or occupation- MI follows the 20 Factor IRS Test which generally assesses the degree of control held over the worker State and Municipal Workers On-Call Municipal Workers Persons in service of another
Statutory Employment
If general contractor hires a subcontractor who does not have coverage, an injured employee of the sub contractor can generally make a claim against the general contractor who is deemed the statutory employer
Employees Not Covered
Federal government employees
Workers on interstate railroads
Nationals of foreign countries
Police Officers and Firefighters who accept “like benefits”
Agricultural Employees and domestic servants
Seaman and those who work on ships
Employee of franchisee is not employee of franchisor unless franchisor exerts control
Personal Injury
A specific act or event that results in a claimed disability
Specific Losses
Injuries for which WDCA provides specific number of weeks of benefits regardless of when employee returns to work
Must either be an amputation or loss of industrial use of body part
If a worker loses 2 or more body parts, deemed total and permanently disabled
Occupational Disease
Disease or disability that is due to causes or conditions that are characteristic of and peculiar to the business of an employer and that arises out of and in the course of employment
Arising out of and In the Course of Employment
Causal Relationship- by a preponderance of the evidence some causal relationship between employment and disability
Aging-Related Conditions
Must show the work contributed to the disability in a significant manner
Psychiatric Disability
Suffered mental disability
Disability arose out of an event that occurred in connection with employment and actually took place
Perception of the event was grounded in fact or reality, rather than delusion or imagination
The events contributed to the mental disability in a significant manner
Traveling to/Leaving From Work
Generally, not covered
Almost all injuries occurring after the employee reaches the employer’s parking lot or while he is on the premises where work is to be performed are covered
Business Trips
Generally covered, look to employers benefit received
Recreational and Social Activities
Will not be covered unless:
Injury occurred on the premises during lunch or recreation period as regular incident of employment
The employer, either expressly or impliedly, brought the activity within the scope of employment, or
The employer derived substantial direct benefit from the activity beyond the intangible value of improving employee health and morale
Horseplay
Compensable unless the actions of the worker arise to intentional and willful misconduct
Factors to consider:
The extent and seriousness of the deviation
The completeness of the deviation
the extent to which horseplay was an ordinary or accepted part of employment, and
The extent to which the nature of employment may be expected to include such horseplay
Establishing Disability
A worker will be considered disabled if an injury or work-related disease has limited the worker’s earning capacity
An injured worker must have a wage loss, give notice of injury within 90 days of the injury, and make a claim for benefits within 2 years of injury
